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Working with a Tobacco-Addicted Dental Patient

By Nevin Zablotsky, DMD

Speaking to patients about their tobacco habits is a difficult subject to broach, but I propose to you that it might be one of the most gratifying things you and your dental team can do, if done properly. There are certain facts about tobacco use that continue to slap us in the face. Every year, 450,000 Americans die from tobacco-related illnesses.1 These include heart disease, stroke, COPD, and cancer. These diseases are chronic in nature, usually making one’s remaining life less than pleasant. In addition, there is an annual economic loss in the United States of $193 billion due to tobacco use,2 at a time that everyone is crying out about the cost of healthcare; and all of this is preventable. This brings us to tobacco’s impact on oral health, and the role that the dental team can play. The oral cavity is literally the first part of the body to receive the insult of tobacco use, be it smokeless tobacco, cigarettes, pipes, or cigars. The dental literature is replete with examples of how tobacco use increases the likelihood of dental caries, periodontal disease, leukoplakia, and oral cancer.

In the 2006 Journal of Military Medi­cine, a review of the dental health of 66,484 US Army active-duty soldiers showed an increased caries risk due to tobacco use. Some have attributed this increased risk of dental caries to an increase in the acidity level of the mouth from smoke due to a decrease in the buffering capacity of saliva.3 It is clear that the addition of sugars to chewing tobacco and snuff also has enhanced the likelihood of caries.

The 2004 U.S. Surgeon General’s report on tobacco use stated that “the evidence is sufficient to infer a causal relationship between smoking and periodontitis.” It has been estimated that 52% of the 8.1 million cases of chronic periodontitis seen in the United States can be attributable to cigarette smoking.4 Studies have demonstrated that smokers had a marked increase in radiographic evidence of furcation involvement,5 more alveolar bone loss,3 less reduction in probing depths, less gains in clinical attachment after surgical intervention,6 and a higher incidence of tooth loss during maintenance.7 Multiple studies have also concluded that the failure rate of implants dramatically increases with the use of tobacco.8 Most importantly, it also has been shown that smoking cessation can reduce the risk of periodontitis.9

Clearly, the most horrific and life threatening of all tobacco’s oral effects is oral and pharyngeal cancer. There are approximately 35,000 newly diagnosed cases of oral and oral pharyngeal cancer every year in the United States, with one person dying every hour from this terrible disease. The 5-year survival rate is less than 60% and the mortality rate has remained unchanged in the past 40 years. A full 75% of these cancers can be attributed to tobacco use. Given that, to a significant degree, this a preventable disease, the importance of the role of the dental team in helping their patients to quit their tobacco use cannot be overstated.

In the March 2011 edition of the Journal of Periodontology,10 the authors discussed the knowledge, attitudes, and behaviors of periodontists in the United States related to tobacco-intervention cessations. Their conclusions were that the primary perceived barriers to providing tobacco cessation were low patient acceptance of treatment, lack of time, and lack of training. In addition, they found that periodontists believed that interventions were the responsibility of the dental profession.

Based on the evidence, it is imperative that tobacco-related issues be taught in undergraduate and postgraduate dental training programs. The more familiar dentists are with tobacco and its oral and systemic implications, the more comfortable they will be in discussing it with their patients. They will have a better knowledge of the addictive process, and how and when to speak to their tobacco-using patients. In addition to tobacco education, dentists can be taught motivational interviewing techniques, which help to affect positive behavioral changes. They can then apply these techniques to all aspects of their interaction with patients. They will no longer be concerned that they may “frighten away” these patients, but learn that this will enhance their practices in their patients’ eyes, and may become a practice builder.

This author proposes that organized dentistry lend its support in encouraging the addition of this information in training programs, and at local and annual meetings. This year he lectured at dental schools in Barcelona and Seville, Spain. These training programs were impressive in the quality of their educational curricula, and their enthusiasm in addressing what they could do to help their tobacco-using patients. Earlier in the year, the author found the same level of enthusiasm when addressing dental students in Boston, and dental residents and staff in Baltimore.

If a dental practice gets even one person to stop smoking in a year, it not only impacts that individual, but their family members and friends as well. It shows them that it is possible to quit, and in addition, their oral health improves as well. There is no higher level of gratification than saving a life, and we are in a position to do just that.